Utilization of psychiatric consultation for elderly patients

Consultation—liaison in an old age psychiatry service

This retrospective study looks at the outcome of 71 consecutive liaison referrals. Placement was noted at three-month follow-up and further use of medical, psychiatric and social services, compliance with clinical management and recommendations was also measured. Nearly half the patients had dementia and about half had a functional disorder. In 90% of referrals the recommendations were followed. At three-month follow-up 17% had died, 26% had further medical hospital admission, 39% had moved into a continuing care facility (residential/nursing home), and over half had further contact with the old age psychiatry services.

The rising demand for consultation-liaison psychiatry for older people: comparisons within Liverpool and the literature across time

OBJECTIVES

To compare the rate of referrals of older people for consultation-liaison psychiatry services over time within Liverpool and with the literature.

METHODS

All referrals to the liaison psychiatry service for older people in Liverpool between 1999 and 2004 were used to calculate referral rates and compared with data from the same hospital from 1981 to 1989 previously published. Data related to referral rates was extracted from other published studies to allow cross-national comparisons over time.

RESULTS

Between 1999 and 2004 there were 2760 referrals to the Liverpool liaison psychiatry service for older people producing an average annual referral rate of 2.89%. This compares to a referral rate of 0.7% in 1981 and 1.34% in 1989. Comparison with studies from the UK, North America, Europe, Singapore and Taiwan shows an increasing trend across a 30 year period. The rate of referral increases with increasing age up to age 90.

CONCLUSION

Trends indicate increasing rates of referral of older people to consultation-liaison psychiatry services with greater representation of the older old. Similar effects are likely to be experienced in all nations with an ageing population. Liaison psychiatry services will need professionals trained in old age psychiatry if the needs of this increasing elderly population are to be addressed.

Geriatric Liaison: An Approach to Medical Management on a Psychogeriatric Unit in a General Hospital

Cette étude descriptive et rétrospective s'est déroulée dans une unité psychogériatrique d'un hôpital universitaire sur une période de deux ans. Les caractéristiques démographiques, la médication et les motifs de la fin du séjour de 98 patients ont été observés. Les gériatres de l'unité ont vu 39.8 pour cent des patients. Les hommes ont un besoin plus élevé que les femmes de soins d'un gériatre. La durée de séjour est plus élevé pour ceux qui ont une consultation gériatrique. Les diagnostics les plus fréquents sont de l'ordre des troubles affectifs. La consultation est justifiée par des affections neurologiques et cardiaques. L'encadrement offert par l'unité gériatrique est excellent pour la formation gériatrique et psychiatrique.

A comparison of psychiatric consultation between geriatric and non-geriatric medical inpatients

OBJECTIVE

The authors examine changes in psychiatric referral patterns for geriatric inpatients since last reported in the United States, more than 20 years ago, and compare geriatric psychiatric referrals to those of a non-geriatric cohort.

METHOD

Retrospective study comparing psychiatric diagnosis, treatment and aftercare of younger (ages 18-60 years, n = 474) and older (>60 years, n = 487) patients seen in psychiatric consultation in a large, urban, university-based tertiary care hospital setting.

RESULTS

Compared to previous reports in the literature, this cohort contains a notably higher percentage of the 'old-old' (>80 years), reflecting the general aging of those who are hospitalized. Compared to younger patients, geriatric inpatients were more commonly referred for psychiatric consultation, but overall rates of referral remain low (<4%). Geriatric patients were diagnosed with dementia and delirium more frequently; with substance dependence less frequently; and were just as likely to be diagnosed with depression. Geriatric patients were also more likely to receive atypical antipsychotic medications and less likely to receive benzodiazepines than younger patients. In patients diagnosed with depression, psychiatric follow-up is more likely relegated to outpatient geriatricians and nursing homes.

CONCLUSIONS

Consulting psychiatrists frequently encounter geriatric patients and, given patterns of diagnosis and aftercare, should play a major role in medical staff education and in development of enhanced in-hospital and aftercare services, including psychiatric liaison.

Predictors and outcomes of outpatient mental health care: a 4-year prospective study of elderly Medicare patients with substance use disorders

BACKGROUND

Many elderly inpatients have substance use disorders; recent treatment guidelines suggest that they should receive regular outpatient mental health care after discharge from hospital.

OBJECTIVE

The prevalence, predictors, and outcomes of outpatient mental health care obtained by elderly Medicare patients with substance use disorders were examined.

RESEARCH DESIGN

A longitudinal prospective follow-up was performed.

SUBJECTS

Data from Medicare Provider Analysis and Review Record and Part B Medicare Annual Data were used to identify elderly inpatients with substance use disorders (n = 4,961) and determine their outpatient mental health care 4 years following hospital discharge.

RESULTS

Only 12% to 17% of surviving elderly substance abuse patients received outpatient mental health care in each of 4 years after discharge. Cumulatively over 4 years, approximately 18% of surviving patients obtained diagnostic/evaluative mental health services, 22% obtained psychotherapy, and 9% received medication management. Of patients who obtained outpatient mental health care, 57% made 10 or fewer outpatient mental health visits over the entire 4 years. Younger, non-black, and female patients were more likely to obtain mental health outpatient care, as were patients with prior substance-related hospitalizations, dual diagnoses, and fewer medical conditions. Prompt outpatient mental health care was predictively associated with higher likelihood of mental health readmissions and, among patients with drug disorders, lower mortality.

CONCLUSION

Very few elderly Medicare substance abuse patients obtain outpatient mental health care, perhaps because of health or economic barriers.

Geriatric psychiatry consultation in the community

While increasing emphasis is being placed on geriatric psychiatry consultation and outreach services, there is considerable variation in terms of the composition and direction of these programs. Programs vary in terms of their objectives, location, target population, use of health professions and other resources and their method of consultation. The purposes of this paper are to review the characteristics of existing programs, to review the needs of the targets of consultation and to consider theoretical and methodological approaches which have been found to be useful in mental health/psychiatric consultation, in continuing medical education, and in program evaluation. On the basis of this review, future directions for effective approaches to consultative outreach in geriatric psychiatry will then be proposed.

Developing a financially viable consultation-liaison service

As reimbursement for psychiatry changes, general hospital psychiatry divisions, specifically consultation-liaison (C-L) services, will take on increasingly important roles. This article shows how a variety of funding mechanisms have applications in different hospital systems. Although every recommendation does not apply to each hospital, certain important contributions that C-L psychiatry can make, such as updating diagnosis-related group codes and enhancing hospital reimbursement for services appropriately delivered, are reviewed. Specific recommendations that may be helpful in various hospital systems are offered that, individually and in the aggregate, should enhance the position, as well as the financial, research, and clinical base for an effectively managed C-L service.

Psychiatric liaison referral of elderly inpatient in a medical school hospital

A retrospective study of elderly inpatient referral was carried out at Saga Medical School Hospital in order to assess the effectiveness of consultation-liaison service. A total of 51 patients aged 65 and over were referred to the Psychiatric Department. Their referral rate, clinical characteristic, diagnosis and psychiatric recommendation were reviewed from the records. A comparison of various aspects concerning the referral for the periods before and after the installation of an effective psychiatric consultation-liaison service showed a mild change. The striking finding was that the referral rate increased significantly for male patients under 75 years of age.

The accuracy of older and younger Australians' understanding of mental health and aging

Inadequacies in contemporary mental health care for elderly individuals may come about partly through ignorance of both positive aspects of mental health in old age (e.g., the responsiveness of older clients to psychotherapy) and the negative aspects (e.g., elderly men's unusually high suicide risk). A quiz measuring knowledge of both kinds was administered to a total of 250 Australian men and women aged seventeen to eighty-one years who were either retired, employed, housewives, or university students. As hypothesized, the retired group scored lowest on the quiz, with no significant differences among younger students versus non-students. Age was found to be a more important mediator of the retired group's low scores than gender, living with an older person, or self-definition as retired versus employed or a housewife. A previous finding of higher scores by Australians than by U.S. undergraduates in an aging course was also replicated and extended to older nonstudent groups. Implications of these findings for mental health services for elderly individuals and for educational interventions to improve understanding of mental health in older age groups were considered.

Effectiveness of geriatric psychiatry consultation in an acute care hospital: a randomized clinical trial

OBJECTIVE

To evaluate the effectiveness of geriatric psychiatry consultation in reducing the severity of confusion, anxiety, depression, abnormal behavior, and functional disability among a selected group of aged medical and surgical inpatients.

DESIGN

Randomized clinical trial. Cases assessed on enrollment at 2, 4, and 8 weeks later.

SETTING

Primary acute care hospital.

PATIENTS

Eighty hospitalized patients aged 65 or older who were referred to a multi-disciplinary team and had not received a psychiatric consultation in the month prior to referral. Sixty-three patients completed the trial.

INTERVENTIONS

Patients in the treatment group received a geriatric psychiatry consultation and, when appropriate, follow-up at least once per week for 8 weeks. Control patients received usual medical care.

MAIN OUTCOME MEASURES

Short Portable Mental Status Questionnaire, Anxiety Status Inventory, Geriatric Depression Rating Scale, and Crichton Geriatric Behavioral Rating Scale.

RESULTS

The effect of the consultation on psychiatric symptoms and functional status was positive but small. The differences in scores of all measures between treatment and control groups were not statistically significant, but there were consistent trends for more treatment than control cases to have improved on all measures, significantly so on the Anxiety Status Inventory (P less than 0.05). Cases with delirium or depression improved most often. More control than treatment cases were discharged after 4 and 8 weeks, but twice as many treatment cases were discharged home.

CONCLUSIONS

Geriatric psychiatry consultation, while not highly effective overall, may be beneficial if targeted to those most likely to benefit and compliance by referring physicians can be improved.

Psychogeriatric consultation. General Hospital versus home for the aged

As more elderly persons are institutionalized in long-term care settings, there will be an increasing need for psychiatric consultation-liaison (C/L) services. An understanding of how patterns of C/L service provision differ in these settings from those in the general hospital is important for efficient use of resources. In this study, certain characteristics of psychiatric consultations for the elderly patients in a general hospital were compared to consultations in a home for the aged. Three groups of 30 patients were examined: patients age 60 and over in a general hospital (GH), patients under age 60 in a general hospital (GHY), and patients in a home for the aged (HA). GH and GHY shared many characteristics, but there were significant differences between HA and GH: Consultations for HA were less likely to be urgent and more likely to be for management. Dementia was diagnosed in 70% of HA versus 27% in GH. Types of interventions were similar in GH and HA except that more psychotherapy was done in HA. In HA more contact was made with allied health professionals, while in GH there was more contact with medical personnel. GH patients were seen more intensively during the first 2 weeks following referral. We conclude that the major part-time attendance of a psychiatrist skilled in both the behavioral management of demented patients and liaison with allied health professionals is likely to be sufficient in long-term care institutions for elderly patients. However, the psychiatrist must also be proficient in the education of the staff of the institution so as to encourage the referral of all those patients who require psychiatric attention.

Geriatric and nongeriatric psychiatry consultation. A comparison study

Data from geriatric and nongeriatric psychiatry consultations done on medical and surgical inpatients at a Veterans Administration Medical Center over a 1-year period were analyzed. A total of 750 consultations were conducted. Patients age 60 and over were referred significantly more often for agitation and competency assessment, and significantly less often for suicidal ideation. More than half the older patients had evidence of an organic brain syndrome. Notably fewer geriatric than nongeriatric patients were diagnosed as having personality disorders. Psychotropic medications were prescribed and further medical workups were recommended more often for the elderly. The results have important implications for mental health professionals working with older patients. The need for more training of both psychiatric and nonpsychiatric residents in the management of geriatric patients is discussed.

Psychiatric liaison referrals of elderly in-patients in a teaching hospital

A retrospective review of 131 psychiatric referrals of hospital in-patients aged 65 years and older was made to examine the referral rate, the characteristics of referred patients, and the pattern of diagnoses and recommendations made by the psychiatrist. The referral rate was much less than the estimated prevalence of psychiatric morbidity in similar populations. The majority of referrals received a psychiatric diagnosis, most commonly an organic psychiatric syndrome (37%) or depression (23%). Comparison of various aspects of referral for the periods before and after the introduction of a specific psychiatric liaison service for the elderly showed little change apart from a small increase in referral rate.

Psychiatric disorder in the general hospital

There have been many reports of psychiatric disorder in medical populations, but few have used standard methods on representative patient groups. Even so, there is consistent evidence for considerable psychiatric morbidity in in-patient, out-patient and casualty department populations, much of which is unrecognised by hospital doctors. We require a better classification of psychiatric disorder in the general hospital, improved research measures, and more evidence about the nature and course of the many different types of problem so that we can provide precise advice for their management of routine clinical practice.